Dominion Cove Point LNG, LP

Original Volume No. 1

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Effective Date: 05/01/2003, Docket: RP03-341-000, Status: Effective

Original Sheet No. 493 Original Sheet No. 493 : Effective

REQUEST FOR SERVICE FORM

(Continued)

9. DELIVERY POINT(S)

A. For each requested Delivery Point, list the following:

1. Delivery Measuring Station Name.

2. Quantity to be delivered by Seller (dth/day).

3. Name of downstream entity receiving gas.

Primary Receipt Point: 1. _____________________________

2. _____________________________

3. _____________________________

Secondary Receipt Point: 1. _____________________________

2. _____________________________

3. _____________________________

10. REGULATORY APPROVALS

List any regulatory approvals required by Requestor to commence service:

Requestor certifies that the information contained in this Request for Service is complete

and accurate to the best of Requestor's knowledge and that all regulatory approvals that are

necessary for gas to be received into and delivered from Seller's facilities have

been obtained or applied for by Requestor except as otherwise noted.

Requestor (Buyer):

Signed By :

Title :

Date : / /